Layered Management of Hypertrophic Scars and Keloids: From Silicone and Intralesional Triamcinolone Acetonide Plus 5-Fluorouracil to Adjuvant Strontium-90

Hypertrophic scars and keloids are fibroproliferative scars that can cause disfigurement, pruritus, pain, contracture, and reduced quality of life. Outcomes remain inconsistent because phenotypes vary by anatomic site, thickness, skin type, and time since injury, and no single modality is uniformly curative. We performed a narrative review informed by a structured search of MEDLINE/PubMed, Embase, Cochrane Library, Web of Science, and Scopus (2000 to November 2025), including clinical trials, observational studies, systematic reviews, and consensus guidance with clinically actionable treatment parameters. Evidence most consistently supports early, low-risk modulation with silicone gel or sheets for the prevention and early treatment of hypertrophic scars. For established hypertrophic scars and keloids, intralesional triamcinolone acetonide combined with 5-fluorouracil provides a practical pharmacological backbone, offering more reliable flattening and symptom control than steroid monotherapy. Adjuncts should be selected according to dominant clinical features, including cryotherapy for relatively thin lesions, fractional carbon dioxide laser for thickness and texture, and botulinum toxin A when tension, pruritus, or contracture is prominent. For selected thin keloids, radiotherapy options include external beam techniques and brachytherapy; superficial beta-brachytherapy with strontium-90 may serve as consolidation after response to intralesional therapy or as targeted postoperative adjuvant at high-risk sites. Because pigmentary adverse effects are clinically important in darker skin types, procedural choices should incorporate explicit counseling and conservative parameters. A pragmatic algorithm, reassessment triggers, and a modality summary table are provided to support routine clinical decision-making.